The Pelvic Floor and Preventing Tears
A trauma free, tear free birth is one of the cornerstones of midwifery care. However, It is up to the laboring woman to have the awareness to ease the baby out. Sometimes, this can be easier said than done. If the mother is struggling with sensations or involuntarily contracting the pelvic outlet muscles, a hot compress to the perineum can help her relax and re-focus. Hot compresses are also helpful in stimulating circulation and providing relief from burning at maximum stretch (“ring of fire”). To prepare a hot compress, use sterile gauze pads or a washcloth with a squirt of betadine or another antiseptic agent. Hot compresses are crucial if the perineum blanches at any point. If blanching does occur and a tear seems likely, it is best to have the mother push between contractions. This helps them feel more relaxed and in control while also working to keep the perineum intact.
Another factor in avoiding tears is ensuring the baby’s head is flexed. Birthing in an upright position allows the pelvic floor muscles to promote flexion automatically. If the head is not well flexed, counterpressure can be applied to the perineum when crowning begins so the smallest possible diameter of the head can pass. Counterpressure is also helpful with a rapidly crowning head.
Changing positions can also reduce the risk of tears. A knee to chest position with the butt elevated (think of a modified child’s pose) as well as a side-lying position with one leg raised (peanut ball or pillow between legs) reduces strain on the perineum. Both side lying and hands and knees positions allow for second stage to commence more slowly if a precipitous delivery is anticipated.
Muscle tension can cause an arrest in the perineal phase. Muscle tension can be associated with sexual abuse, a large baby or a fear of tearing. Some of these sensations can be overwhelming and bring up traumatic events, both conscious and subconscious. It is important to allow the mother to feel safe and in control. The process of birthing her baby can empower her to essentially “re-write” past traumatic events and fears into memories of empowerment, strength and unconditional love. Birth is that powerful!! You are that powerful!! Encompassing a mindset of letting go may also help to dissolve muscle tension. Sometimes reaching down to feel the baby’s head often brings the baby spontaneously. A mirror can also be placed at the perineum for visualization.
A first-degree tear involves injury to the perineal skin only. Lacerations are often superficial and occur most often on the labia with torn skin and smooth, intact flesh underneath. Suturing is not recommended in this case as stiches will not hold unless imbedded in the flesh. Internal vaginal tear edges will meet and join together as long as the split is no more than halfway through the muscle. First-degree perineal tears can heal by themselves if the mother takes good care of them. Suturing, however, may help the mother feel more comfortable if the tear edges do not approximate, or fit together easily.
A second-degree tear involves injury to perineal muscles. Episiotomies are labeled as a second-degree tear due to pelvic muscle involvement. To perform an episiotomy, you must cut through muscle. These tears involve the vaginal mucosa, bulbocavernosus muscles and the perineal skin therefore suturing is required. Lacerations are closed in layers – muscle to fascia to skin.
A third-degree tear involves the addition of the anal sphincter muscles. This occurs with a deep tear involving the levator ani muscle which encircles the anus. It can be torn either partially or completely and must be repaired by someone who is experienced. A fourth-degree tear involves the addition of the anal epithelium.